Under the 2014 Children and Families Act for a child/young person with long-term complex needs
A school/setting should demonstrate that they have taken purposeful, relevant and sustained action to meet a child or young person’s special educational needs before making a request for an Education, Health and Care (EHC) Needs Assessment.
Has the school/setting spoken to this child/young person/parents about the processes involved in requesting an EHCC Needs Assessment and are they aware that this request is being made? / Yes/NoSECTION 1: Details about the child or young person.
1a. SETTING / SCHOOL DETAILSName of school/setting submitting request/providing evidence
When was the child/young person admitted to the school/setting?
What was the child/young person’s attendance rate over the last year?
Other schools/settings attended in last 2 years
Dates where known
1b. CHILD/YOUNG PERSON – Please give first names in full, as registered
Surname / First name(s) (in full)
Address
Also known as / previously known as: / D.O.B. / NCY / Gender
What languages are spoken at home? / Religion / Ethnic Origin
Is the child placed out of their chronological year? Y / N / With which year group are they taught? / Under 5s: number of hours attendance per week / Is this child/young person known to Youth Offending Service? Y / N
NHS Number
GP details: / Who would this child/young person like to support them to give their views?
1c. ALL WITH LEGAL PARENTAL RESPONSIBILITY* (please give details of all to be notified) (*definition in Section 6b)
Surname / Title / Surname / Title
First Names (in full) / First Names (in full)
Parent/Guardian/Social Care / Parent/Guardian/Social Care
Address: (if different from child)
Post Code / Address: (if different from child)
Post Code
Tel – home
work
mobile / Tel – home
work
mobile
Email / Email
Has legal parental responsibility? Y /N / Has legal parental responsibility? Y / N
Is parent in the armed forces? Y / N / Is parent in the armed forces? Y / N
1d. SOCIAL CARE INVOLVEMENT
Is the child/young person known to the Social Care, Children & Families Team? Y / N
(If N go straight to Section 2)
Is the child/young person ‘Looked After’ by Social Care?
(e.g. Interim Care Order/Full Care Order/ Accommodated) Y / N
If so - a copy of the Care Plan must be attached Y / n/a
Name of Social Worker / Address of Social Worker
Authority (if not Buckinghamshire)
Telephone
Foster Carer / Surname / First Names (in full) / Title
Foster Carer / Surname / First Names (in full) / Title
Attached is Social Care, Children & Families agreement to request for EHC Needs Assessment / tick
1e. Are there any reasons why it may not be appropriate to visit the family home? Y / N
SECTION 2: Areas of need
2a. How would you summarise the child/young person’s area(s) of need?Evidence of need and support provided must be included with submission.
AREA OF S.E.N. / CATEGORIES OF SENPlease refer to SEN Code of Practice (2014) / Primary Need
Tick ONE only / Additional Needs
Cognition & Learning / Specific Learning Difficulties
Moderate Learning Difficulties
Severe Learning Difficulties
Profound and Multiple Learning Difficulties
Communication & Interaction / Speech Language and Communication
Autistic Spectrum Disorder
Social, Emotional & Mental Health / Social, Emotional & Mental Health
Sensory and/or Physical / Hearing Impairment
Visual Impairment
Multi-sensory Impairment (i.e. vision & hearing)
Physical Disability
Medical condition / Medical condition affecting education
2b Has this pupil been achieving at below the average range for someone of their age for more than 6 months? / Y/N
2c. Pupil Assessment and Tracking data for example P Levels / NC / Average Point Scale for the last 3 academic years.See table below for EYFS
Subject / NCY / NCY / NCY / Last SATs results / Anticipated End of Year Target:
Date: / Date: / Date: / Date:
English
Reading
Writing
Speaking
Listening
Maths
Numeracy
PSHE
Assessment Data including (social and emotional)
2c. Pupil Assessment and Tracking (EYFS ONLY)
Area of learning and development / Aspect / Age / Age / Age / Anticipated age band at end of school year
Date / Date / Date
For each Aspect please indicate Emerging Developing or Secure within age band
(0-11 8-20 16-26 22-36 30-50 40-60+ months)
Personal, Social & Emotional Development / Making relationships
Self-confidence & self-awareness
Managing feelings and behaviour
Communication & Language / Listening & attention
Understanding
Speaking
Physical Development / Moving & Handling
Health & self-care
2d. SUMMARY OF CONSULTATIONS WITH OUTSIDE AGENCIES. Please indicate current and past involvement with outside agencies
In all cases relevant reports must be attached. Failure to include relevant reports may adversely affect the LA’s future actions.
Still involved / Involved in past
(with in the last 12 months) / Date last seen / Report attached Yes/No
Adult Health Professional, please state which
Adult Services
Audiologist
Child and Adolescent Mental Health Services
Children’s Social Care
Community Paediatrician
Early Years Inclusion Consultant
Educational Psychologist
First response
Health Visitor
Occupational Therapist
Physiotherapist
Portage
Pupil Referral Unit (PRU)
Speech & Language Therapist
Specialist Teacher
Youth Offending Services
Other…..
SECTION 3: Views in support of this request.
3a. Why have you decided to make this request now? What are you hoping that this request will enable you to provide for the child or young person that you are not able to provide within the school/setting SEN resources (including access to services available to schools/settings as part of the local offer e.g. EPS, STS, SALT)3b. Any other information (provide on a separate sheet if wishing to use this information as part of an Appendix B if EHC Needs Assessment is agreed) – provide only information which is relevant to this child/young person’s Special Educational Needs
3c. Please list the desired SMART, long term outcomes for this child/young person
SECTION 4: Checklist of documentary evidence enclosed. (in addition to reports detailed in section 2d)
4a. Essential documents enclosedSEN Support Plans / Reviewed IEPs / Provision Maps / “All About Me” information / Attendance Certificate (School and Colleges only)
Professional advice / reports
4b. Other documents enclosed (optional)
Medical diagnoses / PRU report and Family Outcomes Star / Development Matters summary (preschools only)
Failure to complete this form as fully as possible, including full details of how the child/young person’s whole SEN funding allocation* has been/will be utilised, may result in a request being turned down because of a lack of evidence at the panel meeting. If you are unable to do this because of a sudden change in the child/young person’s circumstances (e.g. traumatic injury), please make this clear in your submission.
* Please refer to relevant BCC guidance on funding of support
Please return completed form with additional documentation to:
S.E.N. Team
County Hall
Aylesbury
HP20 1UZ
Head Teacher/Setting Manager’s Signature: ______
Name (Printed): ______
Date: ______
It would be helpful if you would provide contact details for your SENCO in case further information is required:
SENCO NAME ______
TELEPHONE NUMBER ______
Section 5a Parents’ Consent for children of statutory school age or under, or if over statutory school age and parents have Deputyship through the Court of Protection
PARENTAL CONSENT TO SHARE INFORMATION AND SEEK ADVICE FROM OTHER PROFESSIONALS
(to be completed by person with parental responsibility – see Section 6b for definition)
Name of child / young person: / D.O.B.:I agree with the decision to request an EHC Needs Assessment and understand that this will involve sharing of information about my child between professionals who will support the Local Authority in deciding whether or not to proceed with an EHC Needs Assessment.
I agree that the Local Authority may proceed with an EHC Needs Assessment if this is deemed appropriate.
I agree that the Local Authority may share information about my child with relevant professionals who have had involvement with my child in the past or who may be asked for advice as part of an EHC Needs Assessment, and that these professionals may provide information to the Local Authority if requested to do so, these may include:
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· Current/Potential Future Educational Setting(s)
· Pupil Referral Unit
· Educational Psychologist
· Specialist Teachers
· Early Years/Portage Team
· Social Care
· Youth Offending Team
· Community Paediatrician or GP
· Speech and Language Therapist
· Occupational Therapist
· Physiotherapist
· Adult/Child and Adolescent Mental Health Services
· NHS (medical) Consultants
· Any other Local Authority or NHS Service involved
[Type text]
Signature: / Date:Print Name:
Relationship to child
[Type text]
Section 5b: Parents’ View
PARENTAL VIEWS
Pupil’s name: / D.O.B.Please provide information under the following headings:
· Our family history/education history
· What is important to us as a parent(s)?
· How to support us as a family
· What’s working well?
· What we want in the future for our child
Signature: / Date:
Print Name:
Relationship to child
Section 6a Young Person Consent (only for Young People who are over statutory school age)
YOUNG PERSON CONSENT TO SHARE INFORMATION AND SEEK ADVICE FROM OTHER PROFESSIONALS
(to be completed by the young person concerned when over statutory school age)
Name of young person: / D.O.B.:I agree with the decision to request an EHC Needs Assessment and understand that this will involve sharing of information about me between professionals who will support the Local Authority in deciding whether or not to proceed with an EHC Needs Assessment.
I agree that the Local Authority may proceed with an EHC Needs Assessment if this is deemed appropriate.
I agree that the Local Authority may share information about me with relevant professionals who have had involvement with me in the past or who may be asked for advice as part of an EHC Needs Assessment, and these professionals may share information about me with the Local Authority, these may include:
[Type text]
· Current/Potential Future Educational Setting(s)
· Pupil Referral Unit
· Educational Psychologist
· Specialist Teachers
· Social Care
· Youth Offending Team
· Community Paediatrician or GP
·
· Speech and Language Therapist
· Occupational Therapist
· Physiotherapist
· Adult/Child and Adolescent Mental Health Services
· NHS (medical) Consultants
· Any other Local Authority or NHS Service involved
[Type text]
Signature ______Date ______
Print Name ______
Name and Address of GP (in case contact needed):
[Type text]
Section 6b Definitions – Young Person & Parental Responsibility
*Young Person (Definition):
You are a Young Person when you are no longer of statutory school age i.e. the end of June of Year 11. (A Young Person should sign this unless s/he does not have mental capacity to do so, in which case evidence of lack of mental capacity should be provided.)
*Parental Responsibility (Definition):
You automatically have parental responsibility if you are the child’s mother, if you have adopted the child, if you are the child’s father and are married to the child’s mother, or you have been registered on the birth certificate as the father since December 2003. You do not automatically have parental responsibility if you are not married to your child’s mother (unless, since December 2003 you have been registered on the birth certificate as the father), or if you are not the natural or adoptive parent.
Section 6c Child/Young Persons Views
CHILD/YOUNG PERSONS VIEW
Pupil’s name: / D.O.B.This advice can be completed by the child/young person using their preferred method of communication, e.g. Makaton, PECS with or without adult support
· What are you likes and dislikes?
· What do you want from your education?
· What are you good at and enjoying doing either in or out of school?
· What challenges do you face?
· What help do you need to manage your difficulties?
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